A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Contact the client's caregiver to discuss the client's comment.

Review the medical record to see if the client has reported abuse in the past.

Report the suspected abuse to the nurse manager.

Restrict family members from visiting with the client.

Answer and Explanation

The Correct Answer is B

A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.

B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.

C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.

D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.

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Correct Answer is A

Explanation

A. A teenage boy is the correct answer. The HPV vaccine is recommended for males and females starting at age 11 or 12, but it is most effective when given before any sexual activity. The vaccine can be administered through age 26 for individuals who were not vaccinated at the appropriate age.

B. An older adult woman is not typically recommended for the HPV vaccine. The vaccine is most effective when given before exposure to the virus, typically in preadolescent girls and boys. Women over the age of 26 may not benefit as much from the vaccine.

C. A preschool-age girl is unlikely to receive the HPV vaccine at this age, as it is usually given starting at age 11 or 12, ideally before the onset of sexual activity.

D. A middle adult man may still receive the HPV vaccine if not previously vaccinated, but it is primarily recommended for individuals under age 26.

A. "Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals." B. "Drink at least 240 milliliters of water during each meal." C. "Perform pulmonary hygiene 1 hour before meals." D. "Lie down for 30 minutes after eating."

Correct Answer is C

Explanation

A. "Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals." is incorrect. Oxygen should not typically be increased during meals unless specifically prescribed by the provider. If the client has difficulty eating due to breathlessness, a more individualized plan is needed.

B. "Drink at least 240 milliliters of water during each meal." is incorrect. Clients with COPD may have difficulty breathing when consuming large amounts of fluids during meals. Overhydration could also worsen fluid retention in some cases. The amount of fluid should be tailored to the client’s needs and prescribed by the healthcare provider.

C. "Perform pulmonary hygiene 1 hour before meals." is correct. Pulmonary hygiene (such as postural drainage, coughing techniques, and deep breathing exercises) should be performed before meals to clear the airways and improve the ability to breathe while eating, preventing aspiration and difficulty breathing.

D. "Lie down for 30 minutes after eating." is incorrect. Lying down after eating can increase the risk of aspiration, especially in clients with COPD who may already have a compromised respiratory system. The client should be advised to remain upright after meals to prevent reflux and aspiration.

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A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Nursing Test Bank

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